Senate Bill 346 History
Senate Bill No. 346
s Prezioso, Foster, Jenkins,
Stollings, Unger, Boley,
Caruth, Kessler, Laird, Wells and Plymale
[Introduced January 25, 2010; referred to the Committee on Health
and Human Resources; and then to the Committee on Banking and
A BILL to amend and reenact §16-1A-1, §16-1A-2, §16-1A-3 and
§16-1A-5 of the Code of West Virginia, 1931, as amended; and
to amend said code by adding thereto five new sections,
designated §16-1A-6, §16-1A-7, §16-1A-8, §16-1A-9 and
§16-1A-10, all relating to credentialing of health care
practitioners; establishing a single statewide credentialing
verification organization; setting forth legislative findings;
defining key terms; providing for contracting authority;
setting forth an application process; providing for the
confidentiality of information; setting forth legislative
rule-making authority; providing for the establishment of fees
and penalties; and granting immunity to credentialing entity
for reliance upon information provided by the statewide
credentialing verification organization.
Be it enacted by the Legislature of West Virginia:
That §16-1A-1, §16-1A-2, §16-1A-3 and §16-1A-5 of the Code of
West Virginia, 1931, as amended, be amended and reenacted; and that
said code be amended by adding thereto five new sections,
designated §16-1A-6, §16-1A-7, §16-1A-8, §16-1A-9 and §16-1A-10,
all to read as follows:
ARTICLE 1A. UNIFORM CREDENTIALING FOR HEALTH CARE PRACTITIONERS.
§16-1A-1. Legislative findings; purpose.
(a) The Legislature finds:
(1) Credentialing, required by hospitals, insurance companies,
prepaid health plans, third party administrators, provider networks
and other health care entities, is necessary to assess and verify
the education, training and experience of health care practitioners
to ensure that qualified professionals treat the citizens of this
Currently, a credentialing application form has Although
uniform credentialing and recredentialing application forms have
been created to reduce duplication and increase efficiency, Each
health care credentialing entity performs continues to perform
primary source verification for the practitioners who apply to that
entity for affiliation. Moreover, because credentialing entities
do not follow a common calendar, practitioners are required to
respond to requests throughout the year from various credentialing
entities seeking essentially similar information. This duplication
of primary source verification is time consuming and costly.
(3) The Secretary of the Department of Health and Human Resources and the Insurance Commissioner share regulatory authority
over the entities requiring credentialing.
(b) The purpose of this article is to continue the advisory
committee previously established to assist in developing a uniform
and to develop legislation regarding the use
of uniform credentialing through one or more credentialing
verification organizations in this state through the development of
legislative rules to govern how a single credentialing verification
organization will operate in this state and, except with respect to
health care facilities, the establishment of a common credentialing
§16-1A-2. Development of uniform credentialing application forms
and the credentialing process.
Notwithstanding any provision of this code to the contrary,
the Secretary of the Department of Health and Human Resources and
the Insurance Commissioner shall jointly propose rules for
legislative approval in accordance with the provisions of article
three, chapter twenty-nine-a of this code governing the development
and use of uniform application forms for credentialing,
recredentialing or updating information of health care
practitioners required to use the forms and the improvement of the
credentialing process, including creation of a credentialing
verification organization and a uniform recredentialing calendar.
For the purposes of this article, the following definitions apply:
(a) "Credentialing" means the process used to assess and
validate the qualifications of a health care practitioner,
but not limited to, an evaluation of licensure status,
education, training, experience, competence and professional
(b) "Credentialing entity means any health care facility, as
that term is defined in subsection (j), section two, article two-d
of this chapter, or payor or network that requires credentialing of
health care practitioners.
(c) "Credentialing Verification Organization" means an entity
that performs primary source verification of a health care
practitioner's training, education, experience; "statewide
credentialing verification organization" means the credentialing
verification organization selected pursuant to the provisions of
section five of this article.
(d) "Health care practitioner or "practitioner" means a person
required to be credentialed using the uniform forms set forth in the
rule promulgated pursuant to the authority granted in section two,
article one-a of this chapter.
(e) "Insurance Commissioner" or "Commissioner" means the
Insurance Commissioner of the State of West Virginia as set forth
in article two, chapter thirty-three of this code.
(f) "Joint Commission" formerly known as the Joint Commission
on Accreditation of Healthcare Organizations or JCAHO, is a private sector, United States-based, not-for-profit organization that
operates voluntary accreditation programs for hospitals and other
health care organizations.
(g) "National Committee for Quality Assurance" or "NCQA" is a
private, 501(c)(3) not-for-profit organization that evaluates and
certifies credentialing verification organizations.
(h) "Network" means an organization that represents or contract
with a defined set of health care practitioners under contract to
provide health care services to a payor's enrollees.
(i) "Payor" means a third party administrator as defined in
section two, article forty-six , chapter thirty-three of this code
and including third party administrators that are required to be
registered pursuant to section thirteen, article forty-six, chapter
thirty-three of this code, any insurance company, health maintenance
organization, health care corporation or any other entity required
to be licensed under chapter thirty-three of this code and that, in
return for premiums paid by or on behalf of enrollees, indemnifies
such enrollees or reimburses health care practitioners for medical
or other services provided to enrollees by health care
(j) "Primary source verification procedure" means the procedure
used by a credentialing verification organization to, in accordance
with national committee for quality assurance standards, collect,
verify and maintain the accuracy of documents and other
credentialing information submitted in connection with a health care practitioner's application to be credentialed.
(k) "Secretary" means the Secretary of the West Virginia
Department of Health and Human Resources as set forth in chapter
sixteen, article one of this code.
(l) "Uniform application form" or "uniform form" means the
blank uniform credentialing or recredentialing form developed and
set forth in a joint procedural rule promulgated pursuant to section
two of this article.
§16-1A-5. Credentialing Verification Organization.
The Secretary and the Insurance Commissioner shall, with the
advice of the advisory committee, take such steps as are necessary
to select and contract with a credentialing verification
organization that will, beginning no later than July 1, 2015, be the
sole source for primary source verification for all credentialing
entities. The credentialing verification organization selected
shall be responsible for the receipt of all uniform applications,
the primary source verification of the information provided on such
applications, and the updating and maintenance of all information
generated by such activities. The dates on which the use of this
statewide credentialing verification organization is mandatory with
respect to the credentialing of the different classes of health care
practitioners shall be determined by emergency and legislative rules
promulgated pursuant to the authority in section ten of this
§16-1A-6. Contract with statewide credentialing verification organization; requirements.
The Secretary and Insurance Commissioner shall assure that:
(1) Any contract executed with a credentialing verification
organization shall be for an initial contract period of at least
three years, subject to renewals, and the Secretary and Insurance
Commissioner shall, in consultation with the advisory committee,
periodically review the statewide credentialing verification
organization's operations no less often than prior to every renewal.
(2) A credentialing verification organization selected pursuant
to this article must, at a minimum, be certified by the national
committee for quality assurance, be able to demonstrate compliance
with the joint commission's standards for credentialing and with all
federal and state credentialing regulations, and maintain an errors
and omissions insurance policy in amounts deemed to be adequate by
the Secretary and Insurance Commissioner.
(3) Preference shall be given to credentialing verification
organizations organized within the State of West Virginia.
§16-1A-7. Verification process; suspension of requirements.
(a) The statewide credentialing verification organization shall
provide electronic access to the uniform credentialing application
forms developed pursuant to section two of this article.
(b) A health care practitioner seeking to be credentialed must
attest to and submit a completed uniform application form to the
statewide credentialing verification organization and must provide
any additional information requested by such credentialing verification organization: Provided, That a failure to comply with
a reasonable request for additional information within thirty days
may be grounds for the statewide credentialing verification
organization to submit its report to any credentialing entity with
identification of matters deemed to be incomplete.
(c) Except as provided in subsection (d) of this section, a
credentialing entity may not require a person seeking to be
credentialed or recredentialed to provide verification of any
information contained in the uniform application: Provided, That
nothing in this article is considered to prevent a credentialing
entity from collecting or inquiring about information unavailable
from or through the statewide credentialing verification
organization or from making inquires to the National Practitioner
(d) A credentialing entity other than a health care facility
must issue a credentialing decision within sixty days after
receiving the statewide credentialing verification organization's
completed report and, with respect to affirmative credentialing
decisions, payments pursuant to the contract shall be retroactive
to the date of the decision.
(e) If the statewide credentialing verification organization
fails to maintain national committee for quality assurance
certification or, in the opinion of the Secretary and Insurance
Commissioner, is unable to satisfy compliance with the joint
commission's standards or federal and state credentialing regulations, the Secretary and Insurance Commissioner may, under
terms and conditions deemed necessary to maintain the integrity of
the credentialing process, notify credentialing entities that the
requirement, relating to the mandatory use of the statewide
credentialing verification organization, is being suspended.
(f) Notwithstanding any other provision of this code,
credentialing entities may contract with the statewide credentialing
verification organization or another credentialing verification
organization to perform credentialing services, such as site visits
to health care practitioners' offices, in addition to those services
for which the statewide credentialing verification organization is
the sole source.
(a) Upon execution of a release by the health care
practitioner, the statewide credentialing verification organization
shall, under terms established in rule, provide the credentialing
entity with electronic access to data generated.
§16-1A-8. Release and uses of information collected;
(b) In order to assure that information in its files is
current, the statewide credentialing verification organization shall
establish processes to update information as required by
(c) Except as provided in subsection (d) of this section, all
information collected by the statewide credentialing verification
organization from any source is confidential in nature, is exempt from disclosure pursuant to subpoena or discovery, is exempt from
disclosure under the provisions of article one, chapter twenty-
nine-b of this code, and shall be used solely by a credentialing
entity to review the professional background, competency and
qualifications of each health care practitioner applying to be
(d) Credentialing information received by a credentialing
entity from the statewide credentialing verification organization
shall not be disclosed except:
(1) In appeals of credentialing decisions or to peer review and
quality improvement committees: Provided, That such information
shall be afforded the same protection from disclosure as is provided
to other records used in proceedings subject to section three,
article three-c, chapter thirty of this code;
(2) In any matter in which an action or order of a professional
licensing board or other state or federal regulatory authority is
at issue, including any proceeding brought by or on behalf of a
health care practitioner or patient or by a regulatory body that
challenges the actions, omissions or conduct of a credentialing
entity with respect to credentialing decision; or
(3) When authorized by the health care practitioner to whom the
credentialing information relates: Provided, That the health care
practitioner's authorization shall only permit disclosure of
information that he or she provided directly to the statewide
credentialing verification organization.
(e) Upon the expiration of the contract with a statewide
credentialing verification organization, all information collected
in connection with the duties under such contract shall be delivered
to the Secretary and Insurance Commissioner to the extent allowed
by law and subject to any legal requirements applicable to the
sources of such information.
(f) The statewide credentialing verification organization may
enter into contractual agreements to define the data type and form
of information to be provided to users and to give users assurances
of the integrity of the information collected.
§16-1A-9. Rulemaking; fees; penalties.
The Secretary and Insurance Commissioner, in consultation with
the advisory committee, shall propose rules for legislative approval
in accordance with the provisions of article three, chapter twenty-
nine-a of this code on or before January 1, 2012. The legislative
rules must include, but not shall not be limited to, the following
(1) Performance standards for the evaluation of the statewide
credentialing verification organization;
(2) The manner in which the statewide credentialing
verification organization must demonstrate compliance with
credentialing standards and regulations;
(3) Penalties, including fines, for violations of any
provisions of this article;
(4) Duties of the statewide credentialing verification organization and the timelines for completion of its verification
duties and services;
(5) Procedures for maintaining healthcare practitioner files;
(6) The payment system to cover the costs of the credentialing
(7) The use and confidentiality of data generated, collected
and maintained by the statewide credentialing verification
(8) Except with respect to health care facilities, the
methodology for determination and communication of the common
recredentialing date for a practitioner.
If the statewide credentialing verification organization
certifies that information in an application has been verified
according to its primary source verification procedures, any
negligence by the statewide credentialing verification organization
in its collection and verification of such information may not be
imputed to a credentialing entity that receives such information
and, further, such credentialing entity is not liable for damages
arising from its reliance on such information in its credentialing
process unless the credentialing entity knew or should have known
such information was incorrect: Provided, That a credentialing
entity is otherwise liable as provided by law for damages arising
from its credentialing decisions.
NOTE: The purpose of this bill is to establish a single
statewide credentialing verification organization in this state.
Strike-throughs indicate language that would be stricken from
the present law, and underscoring indicates new language that would
§16-1A-3 and §16-1A-5 have been substantially rewritten,
therefore strike-throughs and underscoring have been omitted.
§16-1A-6, §16-1A-7, §16-1A-8, §16-1A-9, and §16-1A-10, are new,
therefore strike-throughs and underscoring have been omitted.
This bill was recommended for passage during the 2010
legislative session by the Legislative Oversight Commission on
Health and Human Resources Accountability.